Transcript Pharmacy involvement in the Patient Discharge and

Texas Hospital Association
Annual Conference 2012
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Overview of clinical pharmacy programs
Case study from Peterson Regional Medical
Center, Kerrville, Texas
Case study from Rolling Plains Memorial
Hospital, Sweetwater, Texas
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Hospital payments are now tied to “quality” in
many areas.
Failure to meet the targets will result in lower
payments.
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Readmissions
Value based purchasing
Hospital acquired conditions
Accountable care organizations
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Many of the quality measures are directly related to
the medication management process
◦ Appropriate timing of medications such as
antibiotics, VTE prophylaxis
◦ Appropriate choice of medications
◦ Appropriate monitoring of medications
For some measures, the link to pharmacy is not as
apparent
◦ Is the patient’s readmission due to poor
medication management in the outpatient
setting?
◦ Has an inaccurate medication history on
admission caused a failed quality measure?
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With the potential for lower payments,
hospitals must manage costs at the same
time that we work on these quality measures.
Pharmacy impacts the overall cost of care
through medication management.
Contracting and purchasing management is
not enough to manage the risk of pharmacy
costs. Medication management through
clinical pharmacy programs is an essential
part of managing pharmacy costs.
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The historical role of pharmacy is managing
the dispensing of medications.
While managing dispensing is still very
important, the practice of pharmacy has
evolved over the past 25 years to include
enhanced clinical pharmacy programs.
◦ Pharmacy education has changed to focus more on
clinical management
◦ Many pharmacists complete residencies and
fellowships and are Board Certified in many
different specialties.
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As clinical practice has evolved, pharmacists
have become members of the multidisciplinary
care team. Pharmacists have different skill
sets and augment the care provided by
physicians and nurses.
Renal
Dosing
Anticoagulation
Management
Kinetics
Dosing
Consults
Collaborative
Rounding
Antibiotic
Stewardship
Common
Clinical Services
Provided by
Pharmacists
SCIP
Measures
Review
Glycemic
Management
Pain
Consultation
Medication
Reconciliation
ED
Pharmacist
IV to PO
Conversions
Ambulatory
Care Clinics
Renal
Dosing
Anticoagulation
Management
Kinetics
Dosing
Consults
Collaborative
Rounding
Antibiotic
Stewardship
SCIP
NPSG’s
Readmissions
Core Measures
SCIP
Measures
Review
Glycemic
Management
Pain
Consultation
Medication
Reconciliation
ED
Pharmacist
IV to PO
Conversions
Ambulatory
Care Clinics
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Gattis, et al, found that outcomes in heart
failure can be improved with a clinical
pharmacist as a member of the
multidisciplinary heart failure team.
◦ All cause mortality and heart failure events were
significantly lower and more patients reached target
range with ACE inhibitors in the patient group with
pharmacist interventions than in the control group.
Gattis WA, Hasselblad v, et al. Reduction in heart failure events by the addition of
a clinical pharmacist to the heart failure management team: results of the
Pharmacist in Heart Failure Assessment Recommendation and Monitoring
(PHARM) Study. Arch Intern Med 1999; 159(16): 1939-45
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In a review of published literature on the
effects of interventions by clinical
pharmacists, Kaboli, et al, found that the
addition of clinical pharmacist services
resulted in improved care for inpatients.
◦ Adverse drug events, adverse drug reactions, or
medication errors were reduced in 7 of 12 trials
reviewed.
◦ Medication adherence, knowledge and
appropriateness improved in 7 of 11 trials
reviewed.
◦ Shorter length of stay was noted in 9 of 17 trials.
Kaboli PJ, Hoth AB, et al. Clinical pharmacists and inpatient medical care: a
systematic review. Arch Intern Med 2006;166(9): 955-64.
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12 randomized trials totaling 2,060 patients
were reviewed by Koshman, et al, to
determine the effect of pharmacist care on
the outcomes of patients with heart failure.
◦ Pharmacist care was associated with significant
reductions in the rate of all-cause hospitalizations
and heart failure hospitalizations
Koshman SL, Charrois TL, et al. Pharmacist care of patients with heart failure: a
systematic review of randomized trials. Arch Intern Med 2008; 168(7): 687-94.
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Bond, et al, found that clinical pharmacy
services reduce patient mortality.
◦ Pharmacist-provided drug protocol management
resulted in the largest reduction in mortality.
◦ Other clinical services also showing a reduction in
mortality included pharmacist admission drug
histories, participation on the CPR team,
participation in medical rounds, and adverse drug
reaction management.
Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital
mortality rates. Pharmacotherapy 2007; 27(4): 481-493.
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Patient focused involvement by pharmacists
◦ For some quality measures, pharmacists take an
active role in the medication management process.
 Adjusting order times on VTE prophylaxis to meet first
post-op day requirements
 Reviewing prophylactic antibiotics for appropriateness
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Process focused involvement by pharmacists
 Development of protocols
 Formulary management
 Assistance with creation of order sets in EHR
 Even with protocols and order sets, pharmacists still must
monitor patients to make sure quality measures are met
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Glycemic management
Management of anticoagulation
Admission medication histories
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Goal is to have blood glucose less than 200 at 6am
on the 1st and 2nd post op days.
Pharmacist developed protocol with appropriate lab
orders and insulin orders
Patients meet goal on post op day 1, but occasionally
fail on post op day 2. Failures are normally for nondiabetic patients and they are only slightly above
target level.
Pharmacist reviewed cases. On post op day 2,
patients begin to eat and insulin orders have to be
adjusted to compensate for meal.
Additional monitoring added on early morning post
op day 2 to allow time for additional intervention if
necessary.
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NPSG 03.05.01 requires an anticoagulation
management program
◦ Pharmacist managed protocols for appropriate use
 Baseline INR and ongoing monitoring
 Dosing adjustments by protocol
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SCIP VTE prophylaxis
◦ Pharmacists select dosing times for post-op enoxaparin.
Although many hospitals have standard administration
times that won’t meet the SCIP guidelines of a dose
within 24 hours of surgery end time, the pharmacist can
adjust the immediate post-op dosing time to meet the
guideline, then schedule subsequent doses at the
standard times.
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If a patient’s medication history is inaccurate,
decisions affecting the patient’s care can be
compromised.
In a pilot study, over 90% of medication
histories for patients admitted through the
emergency department had at least one error.
Risk stratification showed that 1.7% of the
errors found could result in patient harm and
possibly prolong the length of stay.
◦ Many errors in diabetic medications and cardiac
medications
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Pharmacists took responsibility for
completing medication histories on as many
patients admitted through the ED as possible.
Reduction in inappropriate medications
dispensed, resulting in 1.5 fewer doses per
patient per day.
Physician and nursing surveys showed that
the process improved patient safety and
physician and nursing satisfaction.
Length of Stay for HF and Diabetic Patients
5.8
5.6
5.4
5.2
Length of Stay
5
4.8
Linear (Length of
4.6
Stay)
4.4
4.2
June, July, Aug, Sept, Oct, Nov, Dec, Jan,
2011 2011 2011 2011 2011 2011 2011 2012
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Smaller hospitals may not have the staff to
add new programs
Larger hospitals within a system may not
have the structure in place to provide support
to smaller hospitals
Must have administrative and medical staff
support of enhanced clinical pharmacy
programs
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Lack of recognized metrics for clinical
pharmacy programs
Productivity systems do not give additional
credit for clinical programs
◦ In a survey of eight health systems across Texas, no
pharmacy productivity system includes a metric for
clinical programs. Half of systems use billed doses
and the other half use patient days or adjusted
patient days. When clinical programs reduce doses
billed or length of stay, there is less credit for the
additional work to accomplish the goal.
Peterson Regional Medical Center
Kerrville, Texas
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125 bed, general, acute care
Not for profit
60 miles northwest of San Antonio, serving
Kerr and 6 surrounding counties
ACC, Home Care, Hospice, and Acute
Rehabilitation
30,000 ED visits per year
62% of Inpatient Admissions from the ED
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“Re-Engineered Discharge”
Boston University
Reduce readmissions
Bundle:
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DC plan, start on admission
Discharge advocate
Checklist
Education, Literacy level
Reinforce post DC
CQI
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Multidisciplinary PI team
Physician champion
Advocate role
Target population
Adapted checklist
Training
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Additional position?
Inaccurate home medication history
Split responsibilities for discharge process
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Redesigned discharge process
Pharmacy-based medication reconciliation trial in
ED
Clinical Pharmacist involvement
Computerized discharge checklist
Pre-discharge order form
Post discharge phone call script
Live 12/5/11
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Discharges,
ED visits within 72 hours, ED visits within
72 hours due to medication issues
30 day related readmits, 30 day all cause
readmits, 30 day medication readmits
ALOS, Index and Readmit
Patient Satisfaction
Presented by
Rolling Plains Memorial Hospital
Pharmacy
Nursing
Medical Staff
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Look-alike / sound alike medications
High risk medications
Heparin
Insulin
Potassium
Opiates
Anticoagulants
Medication Errors
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Community Acquired Pneumonia and
Surgical Care Improvement Project
◦ Correct antibiotic regimen
◦ Antibiotic timing
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RPMH looked at ways to improve
the medication administration
process - focusing on
automated systems and
technology.
Automated dispensing systems
Bar code technology
CPOE and E-Sign
Medication reconciliation
software
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CLIF Grant $50,000 with a 10%
match from RPMH
THIE Patient Safety
Grant for $5,000
Adjunct grant from
TCQPS and Cardinal
for $10,000
RPMH Capital
Budget
4th Q 2009 -
Purchased and installed PYXIS
units on Med-Surg and in ICU
1st Q 2010 – Purchased and installed med verify
(bar coding) software
3rd Q 2010 – Purchased and installed CPOE
2nd Q 2011 – Purchased and installed med
reconciliation software
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Physician buy-in for CPOE
Cardiopulmonary access to PYXIS for
medications
Bar coding / scanning issues
“Work a-rounds”
Time constraints with Med-Rec software
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One-on-One training with physician’s on
CPOE and E-sign
Educated staff not to do “work a-rounds”
and how they affect patient safety
Added Med-Verify utilization on medication
error follow up form
Continued education for nursing staff on
computer documentation to speed up MedRec process at time of patient discharge
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RPMH uses the NCC MERP Index for
Categorizing Medication Errors
With the added technology we noticed a
15% increase in Category A and Category B
medication errors being reported in 2011.
54% decrease in reported
medication errors from
1Q 2010 to 4Q 2011
NUMBER OF REPORTED MEDICATION ERRORS
70
60
62
50
40
30
37
33
28
28
20
19
12
10
0
1 Q 2010
28
2 Q 2010
3 Q 2010
4 Q 2010
1 Q 2011
QUARTER / YEAR
2 Q 2011
3 Q 2011
4 Q 2011
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Continue to
monitor medication
safety processes
Continue to
monitor & report
medication errors
ACT upon any
variance to our
processes or
systems
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Randy Ball, Texas Health Harris Methodist
Hospital Fort Worth,
[email protected]
Larry Nelson, Peterson Regional Medical
Center,
[email protected]
Mickey Williams, Rolling Plains Memorial
Hospital,
[email protected]
Questions???